Evidence-based medicine: the past and the future of plastic surgery.

Abstract

Sir: Evidence-based medicine has brought a real improvement in how patients are selected and how a study is designed, just to mention two benefits induced by this scientific way of evaluating the medical literature. More recently, plastic surgeons have begun to show more interest in evidence-based medicine, looking for unanswered questions on many aspects of the specialty. However, systematic reviews about plastic surgery topics have frequently shown that it is not possible to submit the data to meta-analysis because of the lack of level I evidence–based studies. In contrast, it is evident that the specialty has evolved over the past 30 to 40 years. This evolution was built not on level I evidence–based studies but on less elaborated studies that have brought to light a series of innovations and improvements in plastic surgery. Some of the material that is available in the literature contains important information that could be used to evaluate techniques and risk in plastic surgery. Therefore, a different method should be used to evaluate the previously published scientific material. It is obvious that the value of articles considered level I evidence should be higher than that of the level II studies. An article classified as level V, such as an expert opinion, should also be considered, but with a much lower value. Using a mathematical formula, each article should be taken into consideration. Therefore, most of the material available could be used with a consequent increase in data availability that could lead the future steps of our specialty. Many scientists who see evidence-based medicine as the perfect way to evaluate past literature would criticize a method such as this. The reason why an alternative method should be used to evaluate old material will be better understood in the example that follows. There was a recent unpublished review in which two treatments (conservative versus a surgical procedure) of clavicle fracture were compared. It followed all the steps of evidence-based medicine. This study found three evidence type I articles in the literature. One was published in the 1970s, another was published in the 1980s, and the third was an article published in 2002. What attracted our attention was that a 2013 article, which will be labeled as level I, had its conclusion based on three old articles. If we consider that surgical and anesthetic procedures have evolved over the past 30 or 40 years, it is really difficult to consider that this article has brought us the best conclusions to support each one of the alternatives—and still this is a level I evidence-based medicine study. In contrast, such articles are always updated on the Cochrane database with new studies, published more recently. Therefore, it will stimulate researchers to develop their studies on this particular subject with all the principles of evidence-based medicine. Specialties are different and evidence-based medicine does not differentiate between them. A limitation that most surgical specialties will face when planning type I studies is to develop double-blind studies, as opposed to studies in internal medicine. Although evidence-based medicine is the best available method of making a trustworthy literature review, part of the previous published knowledge is lost. For this reason, evidence-based medicine will always be an important method for systematic literature review; however, another more focused weapon of medical literature review should be available. Finally, we believe that the best role of evidence-based medicine is to guide the study design of future articles to improve quality data on plastic surgery studies. Therefore, although evidence-based medicine is not the best instrument for evaluating the past literature, it is definitely essential for the quality of future articles. By following these principles, in the future, more articles will be available for meta-analysis, thus defining the risk of complications, the best type of procedure, and a more accurate diagnosis in plastic surgery. Plastic and Reconstructive Surgery scored a goal when the Editorial Board decided to use evidence-based medicine as a parameter for evaluating future articles, classifying them based on the level of evidence. This will certainly increase the impact factor of the Journal and, most importantly, will develop plastic surgery to a new scientific level. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Fabio Xerfan Nahas, M.D. Ph.D., M.B.A. Lydia M. Ferreira, M.D., Ph.D., M.B.A. Federal University of São Paulo São Paulo, Brazil